LCA 911 Template

D - (DISPATCH INFORMATION)

[date name="variable_1" default="05-07-2024"]    DISPATCHED PRIORITY __ to  above location. (patient information and dispatch reason).
 
C - (CHIEF COMPLAINT)
COMPLAINING OF (REASON FOR 911 CALL):[textarea name="variable_2" default=""]
 
H - (HISTORY OF PRESENT ILLNESS)
SEE ABOVE FOR MEDICAL HISTORY/CURRENT MEDICATIONS/ALLERGIES
 
LAST ORAL INTAKE: [textarea name="variable_3" default=""]
 
EVENTS LEADING UP TO THE CALL:[textarea name="variable_4" default=""]
 
A - (ASSESSMENT FINDINGS)
ON SCENE PRIOR TO EMS ARRIVAL: [textarea name="variable_5" default=""] 
 
TREATMENTS PRIOR TO EMS:
 
ONSET (WHEN DID THIS START):[textarea name="variable_6" default=""]
 
PROVOCATION (WHAT MAKES IT BETTER OR WORSE):[textarea name="variable_7" default=""]
 
QUALITY (DESCRIBE IT, CONSISTENT/CHANGES):[textarea name="variable_8" default=""]
 
REGION/RADIATION (AFFECTED AREA, PREVIOUS ISSUES):[textarea name="variable_9" default=""]
 
SEVERITY (PAIN SCALE, ACUTE OR CHRONIC PROBLEM):[textarea name="variable_10" default=""]
 
TIME (HOW HAS IT PROGRESSED):[textarea name="variable_11" default=""]
 
ADDITIONAL ASSESSMENT FINDINGS:
 
Assessment:
GENERAL: [textarea name="appearance" default=" Interacting with EMS appropriately; well appearing; not acutely distressed. "]
CNS: [textarea name="CNS" default=" Alert and oriented to person, place, time, and situation. Cranial nerves intact with normal facial movements, visual fields, and gag reflex. Motor strength and coordination normal in all four extremities."]
PSYCH: [textarea name="psych" default=" No reported recent or active suicidality or homicidal ideations. No reported recent or active visual/auditory disturbances. "]
CARDIOVASCULAR: [textarea name="cardiovascular" default=" No immediate concerns. Equal radial pulses bilaterally. "]
PULMONARY: [textarea name="PULM" default=" No initial immediate concerns. Normal and adequate tidal volume and respiratory drive. "]
GI/GU: [textarea name="GIGU" default=" No nausea or vomiting. No changes in bowel reported. No changes in urine reported. "]

Physical Exam:
HEAD: [textarea name="head" default=" No noted pain or trauma. Pupils equally round/reactive at 4mm in size. No facial droop. "]
NECK: [textarea name="NECK" default=" No noted pain or trauma. No JVD. No midline pain. "]
CHEST: [textarea name="chest" default=" No noted pain or trauma. Equal rise and fall. Breath sounds CTA bilaterally. "]
BACK: [textarea name="back" default=" No noted pain or trauma. "]
ABDOMEN: [textarea name="abd" default=" No noted pain or trauma. Soft, flat, non-tender. "]
PELVIS: [textarea name="pelvis" default=" No noted pain or trauma. Stable. "]
EXTREMITIES: [textarea name="extremities" default=" Extremities warm, well-perfused with intact sensation and normal range of motion. Pulses palpable and symmetric bilaterally: radial, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis. No edema or cyanosis noted. "]
SKIN: [textarea name="skin" default=" Skin warm, dry, and intact without lesions or rashes. Capillary refill less than 2 seconds in all extremities. "]
VITALS: [textarea name="vitals" default=" "]
EKG: [textarea name="ekg" default=" "]
 
R - (TREATMENT ON SCENE)
TREATMENTS ON SCENE:[textarea name="variable_12" default=""]
 
PT WAS MOVED TO THE COT VIA:[textarea name="variable_13" default=" Pt was placed in a position of comfort and secured with 5 point straps and rails."]
 
T - (TRANSPORT INFORMATION)
TREATMENTS EN ROUTE:[textarea name="variable_14" default="Patient was transported non-emergent to HOSPITAL with pre-arrival notification made enroute  Pt was continuously monitored throughout transport. During transport patient remains stable."]
 
RADIO REPORT:[textarea name="variable_15" default=""]
 
PT WAS TRANSPORTED TO:[textarea name="variable_16" default=""] 
 
PT WAS TAKEN TO ROOM:[textarea name="variable_17" default=""]
 
PT WAS MOVED TO BED VIA:[textarea name="variable_18" default=""]
 
PT CARE WAS TURNED OVER TO: [textarea name="variable_19" default="Upon arrival at ED handoff given to nurse and provider at bedside. Patient signs PCR."]
 
PT'S PERSONAL BELONGINGS:[textarea name="variable_20" default=""]
BELONGINGS LEFT WITH:[textarea name="variable_21" default=""]

No further care.

[checkbox name="Student" value="*Some assessments and procedures were performed by paramedic student who was under my direct supervision as the attending paramedic, and consistent with student's scope of practice.*"]
[checkbox name="Disclaimer" value="*Please note that this dictation was completed with computer voice recognition software. Oftentimes unanticipated grammatical, syntax, homophones, and other interpretive errors are inadvertently transcribed by the computer software. Please disregard these errors. Please excuse any errors that have escaped final proofreading.*"]